Quackademic medicine triumphant (yet again): A defense of acupuncture on the Harvard Health Blog that misses the point

Every so often, I mention that there was a time about 10-15 years ago when I thought that there just might be something to acupuncture. Sure, I never accepted the mystical magical mumbo jumbo ideas behind acupunctures, such as how it somehow redirects the flow of qi or that there are “meridians” along which this qi flows. After all, unlike a lot of forms of alternative medicine that were clearly quackery, acupuncture actually involved inserting needles into the body. So I thought that maybe there was something, some mechanism by which acupuncture might accomplish some health benefits.

Unfortunately, in the world of quackademic medicine, where quackery has infiltrated bastions of academic medicine, acupuncture is the gateway woo that leads to the harder stuff, like homeopathy (brought in by naturopaths) or “energy medicine.” Nowhere is that more apparent than at that supposed pinnacle of American academic medicine, Harvard Medical School. Unfortunately, Harvard has a thing for woo, including acupuncture. It’s even more than that, though. For example, Harvard has for at least ten years offered a course that it calls The International Structural Course for Physicians: A Palpation-Based Approach. If you’re a physician, you can get over 300 continuing medical education credits for taking the course, as well.

So maybe it shouldn’t be surprising that I came across a post on the Harvard Health Blog entitled Acupuncture for headache. It was written by Helene Langevin and Carolyn A. Bernstein. I note that I’ve written about Langevin on at least two occasions before. First, it appears that she’s moved up in the world, because the last time I took note of her she had co-authored arisibly bad study in which the authors claimed to have identified anatomic structures corresponding to actual acupuncture meridians. There are, of course, no known physiological or anatomic structures that correspond to acupuncture meridians, which brings up the question of how it was that practitioners of traditional Chinese medicine “identified” these channels in the first place. Science can’t tell the difference. Meridians don’t correspond to any nerves, and there’s no physical criteria by which meridian can be distinguished from non-meridian other than magic and fairy dust. None of this stopped Langevin from trying to use a combination of ultrasound and impedance measurements in a tour de force of what Harriet Hall so famously dubbed Tooth Fairy Science. Contrary to their conclusions, the failed to find them. I also can’t help but note that, at the time I last wrote about Langevin, she was still at the University of Vermont. Now she’s Director of the Osher Center for Integrative Medicine at Harvard Medical School and Brigham and Women’s Hospital. She’s moved up in the world.

The other co-author is Carolyn Bernstein, who happens to be a neurologist at the Osher Clinical Center, specifically a Headache Medicine Specialist.

So what do Langevin and Bernstein have to say under the imprimatur of the mighty Harvard Medical School? Nothing good, at least scientifically speaking:

It is easy to ridicule a 2000-year-old treatment that can seem closer to magic than to science. Indeed, from the 1970s to around 2005, the skeptic’s point of view was understandable, because the scientific evidence to show that acupuncture worked, and why, was weak, and clinical trials were small and of poor quality.

But things have changed since then. A lot.

Actually, no they haven’t. The vast majority of acupuncture studies remain small and of poor quality. Even larger trials tend to be of poor quality as well. None of this stops our Harvard faculty members from opining:

Thanks to the development of valid placebo controls (for example, a retractable “sham” device that looks like an acupuncture needle but does not penetrate the skin), and the publication of several large and well-designed clinical trials in the last decade, we have the start of a solid foundation for truly understanding the effectiveness of acupuncture.

I’ve written about a number of those supposedly “large and well-designed clinical trials,” and inevitably I’ve been…underwhelmed. Inevitably, they have serious methodological problems that limit their generalizability. Amusingly, at least one of the studies listed at the end of the post actually found no difference between sham acupuncture and “real” acupuncture, which is the very definition of a negative study.

Next up:

Individual large-scale clinical studies have consistently demonstrated that acupuncture provided better pain relief compared with usual care. However, most studies also showed little difference between real and sham (fake) acupuncture. In order to address this concern, a 2012 meta-analysis combined data from roughly 18,000 individual patients in 23 high-quality randomized controlled trials of acupuncture for common pain conditions. This analysis conclusively demonstrated that acupuncture is superior to sham for low back pain, headache, and osteoarthritis, and improvements seen were similar to that of other widely used non-opiate pain relievers.

Langevin and Bernstein make some extravagant claims as well. For example:

Meanwhile, basic science studies of acupuncture involving animals and humans have shown other potential benefits, from lowering blood pressure to long-lasting improvements in brain function. More broadly, acupuncture research has resulted in a number of insights and advances in biomedicine, with applications beyond the field of acupuncture itself.

This is the sort of expansive statement that cries out for citations to back it up. I perused the list of references, and I couldn’t see what the authors are talking about. Of course, the evidence that could be marshaled in support of each of those statements consists of studies of the usual level of quality used to support the efficacy of acupuncture, namely low quality studies, often not properly controlled. Personally, I also wonder what “insights and advances” in biomedicine”” Langevin and Bernstein mean that go “beyond the field of acupuncture itself.” Certainly, none of their references support this claim. If they mean the study in which the efficacy of acupuncture is claimed to be due to the release of adenosine. Whether they meant this study or not, I cite it because it’s an example of a study that was vastly overinterpreted by acupuncture advocates and not actually relevant to whether acupuncture works or not. It did, however, lead to some major rebranding of a non-acupuncture modality as acupuncture. That reminds me. The “adenosine/acupuncture” studies remind me a lot of the pointless (if you’ll excuse the term) acupuncture studies done by Langevin.

Which is funny, given this passage:

We understand why there may be continued skepticism about acupuncture. There has been ambiguity in the language acupuncture researchers employ to describe acupuncture treatments, and confusion surrounding the ancient concept of acupuncture points and meridians, which is central to the practice of acupuncture. Indeed, the question of whether acupuncture points actually “exist” has been largely avoided by the acupuncture research community, even though acupuncture point terminology continues to be used in research studies. So, it is fair to say that acupuncture researchers have contributed to doubts about acupuncture, and a concerted effort is needed to resolve this issue. Nevertheless, the practice of acupuncture has emerged as an important nondrug option that can help chronic pain patients avoid the use of potentially harmful medications, especially opiates with their serious risk of substance use disorder.

As for a “concerted effort” being needed to “resolve this issue,” that’s utter nonsense. The issue was resolved long ago by anatomists and neuroscientists. Only acupuncture advocates try to torture science, evidence, and logic to make it seem as though there is doubt about that an that acupuncture points might really exist. Let’s just put it this way. There was a good reason why, long ago, I mocked Georgetown University long ago and more recently for having “integrated” acupuncture teaching into first year anatomy class in medical school.

Finally, the authors seem so very, very disturbed that critics criticize acupuncture as pseudoscientific:

A post on acupuncture last year dismissed acupuncture as a costly, ineffective, and dangerous treatment for headache. This prompted us to point out the need for a measured and balanced view of the existing evidence, particularly in comparison to other treatments. Although the responses that followed the article overwhelmingly supported acupuncture, it nevertheless remains a concern that this practice attracts this kind of attack. Acupuncture practitioners and researchers must take responsibility for addressing deficiencies in acupuncture’s knowledge base and clarifying its terminology.

That said, we need to recognize that acupuncture can be part of the solution to the immense problem of chronic pain and opiate addiction that is gripping our society. That this solution comes from an ancient practice with a theoretical foundation incompletely understood by modern science should make it even more interesting and worthy of our attention. Clinicians owe it to their patients to learn about alternative, nondrug treatments and to answer patients’ questions and concerns knowledgeably and respectfully.

Respect is earned. For medical therapy, it is earned by evidence and science supporting the efficacy of that therapy, as well as effect size. More evidence and compelling science = more respect. Greater effect size = more respect. Acupuncture fails on both counts. It has no compelling evidence supporting the contention that it is anything more than a theatrical placebo, and the best evidence that its advocates can present, even if taken at face value and its extreme weakness ignored, supports no more than at best a clinically insignificant effect size.

As for acupuncture being an “ancient practice with a theoretical foundation incompletely understood by modern science,” I laughed out loud when I read that line. Acupuncture is a prescientific, vitalistic practice based on ancient Chinese religion that started out far more akin to sort of bloodletting that “Western” physicians did hundreds of years ago than it is to anything resembling modern science. That’s it’s “theoretical foundation.” Everything else (such as adenosine, “counterirritation,” etc.) are tortured rationalizations grafted on to those ancient ideas by scientists desperate for a scientific explanation and rationale for how “acupuncture works.” Too bad they seldom seem to ask the real question: Does acupuncture work? They simply assume that it does.

The hilarious thing about this blog post is that the post by the acupuncture critic that prompted it is far more on point than Langevin and Bernstein’s rebuttal. The not-so-hilarious thing about Langevin and Bernstein’s post is that it’s yet another indication how quackademic medicine has so completely triumphed in a bastion of medical science as prestigious as Harvard.

27 Comments

When my nursing program went to a concept based curriculum, CAM was one of the concepts. There was a time when I wondered, as Orac did, if there might be something to things like acupuncture. Like Orac, I’ve since come to the conclusion there’s nothing to it.

But the people who persist in believing in it really do believe it. I’ve had two students to presentations based on our CAM concept (I basically teach what it is, and tell students there’s no scientific evidence to support it but that many of their patients will be users of it): one on “chronic Lyme” and another on acupuncture. The girl who presented on acupuncture is from Korea, and actually had a set she brought when she emigrated to the US. It was challenging explaining to the class why acupuncture can’t work when the student sees the practice as wrapped up in her cultural identity.

But since that time, I don’t allow any presentations on alternative practices. I can’t risk any more students bringing woo into my classroom.

The comment about ‘cultural identity’ is particularly relevant. It really is the currency, in lieu of evidence, for practitioners of woo and advocates of right-wing conspiracy theories. The idea is to make it appear that people that insist on evidence are attacking them. It is very hard to counter in any honest way, and leads to the false appearance of two groups engaged in a battle for cultural dominance.

I’m tired of the doublespeak. “Integrative Medicine” is nothing more than magic fairy dust offered at legitimate medical institutions. It doesn’t “help” people do anything other than reject science. “Complementary and Alternative Medicine” is more of the same. Now is the time for legitimate scientists to stop pandering to science illiteracy. Pandering has led to our present day culture where every high school dropout with a computer is a Google genius who is qualified to dispute expert science, reject vaccines, and waste time, money, and health on supplements, tortuous diets, or cancer quackery. People are smart enough to understand basic science if we teach it properly. Unfortunately, most people are not smart enough to see that there are no alternative forms of medicine when said magic is “integrated” with quackery by legitimate medical institutions. We need to stop trying to “reach” people with magical thinking and tell them the truth, with scientific explanations. These people are dangerous. They are undermining medicine, endangering public health, and committing fraud. If an institution such as Harvard doesn’t know any better than to avoid woo and endorse quackery, how can anyone else be expected to know?

It goes beyond a blog post. The lead story for the January 29 HEALTHbeat email from Harvard Medical School ( [email protected] ) “Acupuncture for headache” is the lead story opening with that paragraph “It is easy to ridicule a 2,000-year-old …” Naturally like all charlatan organizations, Harvard is selling their “Special Health Report” for headache at 30% off the $29 cover price:

“In Headache Relief, you’ll find:

A user’s guide to over-the-counter and prescription headache medications
18 migraine-triggering foods from A (avocados) to Y (yogurt)
The headache that strikes men 10 times more often than women
The growing role of hypnotherapy, acupuncture, and biofeedback
A “home-brew” remedy that can ease migraine pain
6 headaches that mean get to the doctor — now."

Tried to ascertain how many subscribers are on their mailing list but could not find that information. Think it would be several thousand.

Often woo is packaged as “wisdom of the ancients”, but in many cases the woo being promoted does not go back nearly as far as its adherents claim, and acupuncture is one of those cases.

As Orac has demonstrated on a number of occasions, what we know today as “traditional Chinese medicine” dates from the 1950s, when Mao Zedong (who preferred science-based medicine, thank you, but knew he didn’t have the resources to deploy it throughout China) distilled a bunch of folk medicine traditions into a semi-coherent system (I use that term generously). Acupuncture is one of those folk medicine traditions. True, techniques called “acupuncture” have been around for a few hundred years. But acupuncture as we know it today requires thin needles. The technology to make sufficiently thin needles in sufficient quantities for a practitioner to use has only been around since, at earliest, the late 19th century, and wasn’t available in China until after Mao came to power.

The other day, I wanted some physiotherapy for my borked knee, found a clinic which offered real doctors with M. D., real therapeutic approaches, had a talk with one of the doctors about my issues, arranged sessions with a physiotherapist, came there and he told me that I need Chinese medicine for my problems as per Dr. So-and-So instructions, it will deal with the underlying problems, yadda yadda… I said that my problem is borked patella and weaker muscles on one leg, the guy said something else about underlying problems, Chinese medicine again, I objected that I want a treatment, not some shamanic dances, mentioned the Mao thing and the therapist claimed that he’s not using Traditional Chinese Medicine which was invented by Mao but Classical Chinese Medicine, with its millenia of accumulated knowledge, the usual stuff.

I’ve always been skeptical of the whole idea of sham acupuncture. Acupuncture points may be inconsistent, but they aren’t hard to learn about, and given the variation in systems you can probably find an appropriate point for whatever body part was meant to represent the placebo. And real acupuncture has enough bruising and bleeding to account for enough broken placebo to skew results into significance.

Ted Kaptchuk (Harvard Medical School) was a co-author and study designer with Langevin of the collagenous meridians study. The belated criticism of acupuncture, prompting Langevin and Bernstein’s response, came from a contributing editor of Harvard Health Publishing.

A tiny bit of pushback from within.

Langevin believes acupuncture to be more than a placebo – she points to Vickers et al. as evidence. Kaptchuck isn’t concerned whether acupuncture is a placebo or not. Non-deceptive placebos work, he believe he has shown.

Whilst there is no unambiguous, agreed definition of acupuncture there is no possibility of an unambiguous placebo. Therefore it is not possible to prove that “acupuncture” is superior to placebo and efficacy becomes an article of faith for believers.

If there were universally clear, well defined points, for well defined conditions, with well defined doses, then a placebo form of acupunture would be possible.

Even the most skillful of nurses will sometimes have to have a second stab at trying to get a needle or catheter into the lumen of a vein, especially when it’s hard to see what’s what. Many procedures involving the sticking-in of something rely on sophistimicated technological aids to hitting the spot. I’m sure our host could fill us in on the risks of missing when doing things like putting in a subclavian central line and various other pokey problems. But somehow it seems acupuncturists can, as far as I’m aware, hit the magical meridian or target on the ear-dwelling homunculus first time, every time. Jus’ don’t seem right to me.

That’s so weird that so many people in the medical profession amuse themselves with trite statements of “woo” and “placebo”, but you can’t run fast enough to get a certification in Medical Acupuncture. Or is it only placebo until you can find a way to make money from it.
I guess, institutions like Memorial Sloan Kettering, NYU Langone, Mt Sinai, Philadelphia Hospital for Children, Cleveland Clinic and others have been hypnotized by the ‘fairy dust’ because they all offer acupuncture. Please help them out of this spell.
Or, better yet, clean up your own house of pill pushers, so your profession stops killing people. https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

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